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Michigan Adult Treatment Protocols ALTERED MENTAL STATUS Date: November 15, 2012-Page 1 of 1 Altered Mental Status The purpose of this protocol is to provide for the assessment and treatment of patients

How to fill out altered mental status

How to fill out altered mental status:

1. Obtain the necessary forms or documentation for recording the altered mental status evaluation.
2. Clearly document the patient's personal information, including their name, date of birth, and medical record number.
3. Begin by documenting the date and time of the evaluation, as well as the name of the healthcare professional performing the assessment.
4. Record any pertinent medical history or pre-existing conditions that may contribute to the altered mental status.
5. Perform a thorough physical examination, documenting any abnormal findings such as vital signs, neurological deficits, or signs of trauma.
6. Assess the patient's mental state by documenting their level of consciousness, orientation to person, place, and time, and any abnormal behaviors or mental status changes.
7. If available, utilize validated assessment scales such as the Glasgow Coma Scale or the Richmond Agitation-Sedation Scale to quantify the severity of altered mental status.
8. Document any laboratory or diagnostic test results that may be relevant to the evaluation, such as blood tests, imaging studies, or toxicology screens.
9. Include a detailed description of the patient's presenting symptoms, including the onset, duration, and progression of the altered mental status.
10. Consider the differential diagnosis and list potential causes or contributing factors to the altered mental status, ensuring to include both medical and psychiatric conditions.
11. Finally, conclude the altered mental status evaluation with a summary and impression, providing a working diagnosis if possible, or a plan for further investigation or management.

Who needs altered mental status:

1. Healthcare professionals working in emergency departments or critical care units often encounter patients with altered mental status due to various medical or neurological conditions.
2. Emergency medical service personnel and paramedics may need to assess altered mental status in individuals found in altered states of consciousness.
3. Primary care physicians may encounter patients with subtle changes in mental status during routine examinations, warranting further evaluation.

It is important to note that altered mental status can occur in people of all ages and can be caused by a wide range of underlying conditions, including infection, drug intoxication, metabolic disturbances, and neurological disorders.

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What is altered mental status?

Altered mental status refers to a change in a person's cognitive function, such as confusion, disorientation, or decreased level of consciousness.

Who is required to file altered mental status?

Healthcare professionals, caregivers, or family members who notice changes in cognitive function in an individual are required to report altered mental status.

How to fill out altered mental status?

Altered mental status can be documented by noting changes in behavior, speech, orientation, or level of consciousness, and reporting these observations to a healthcare provider or appropriate authority.

What is the purpose of altered mental status?

The purpose of reporting altered mental status is to ensure that individuals receive appropriate medical care and intervention to address any underlying causes of cognitive changes.

What information must be reported on altered mental status?

Reports on altered mental status should include details of the observed changes in behavior, cognition, and level of consciousness, as well as any relevant medical history or medications.